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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397004273
Report Date: 04/25/2024
Date Signed: 04/25/2024 11:35:20 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2024 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240228115950
FACILITY NAME:J & M CARE HOMEFACILITY NUMBER:
397004273
ADMINISTRATOR:ARLYN DE LA CRUZFACILITY TYPE:
740
ADDRESS:5766 FRED RUSSO DRIVETELEPHONE:
(209) 915-3961
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 5DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Arlyn De La CruzTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff made inappropriate comments towards resident
INVESTIGATION FINDINGS:
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On 4-25-24 at 10:16am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced at facility to deliver findings for the allegation noted above. LPA met with Administrator Arlyn De La Cruz and explained the purpose of the visit. LPA displayed identification upon entry. During this investigation, LPA conducted interviews with two staff members and three residents in care. LPA also reviewed facility file documentation including appraisal and physician report for resident1 (R1).
Allegation: Staff made inappropriate comments towards resident. LPA conducted interviews and record reviews as stated above. Based on interviews conducted, it was determined that R1 and S1 engaged in a verbal exchange of inappropriate language during R1’s residency at the facility. The contents of this verbal exchange included R1 using foul language towards S1 to which S1 responded with foul language directed at R1. As a result, the preponderance of evidence standard has been met, and this allegation is SUBSTANTIATED.
Deficiencies are cited and noted on LIC 9099D. An exit interview was conducted with Arlyn De La Cruz and a copy of this report was provided to Arlyn. Appeal rights provided.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20240228115950

FACILITY NAME:J & M CARE HOMEFACILITY NUMBER:
397004273
ADMINISTRATOR:ARLYN DE LA CRUZFACILITY TYPE:
740
ADDRESS:5766 FRED RUSSO DRIVETELEPHONE:
(209) 915-3961
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 5DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Arlyn De La CruzTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not ensure resident was provided comfortable accommodations for sleeping
Staff did not ensure resident had proper clothing violating residents rights
INVESTIGATION FINDINGS:
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On 4-25-24 at 10:16am Licensing Program Analyst (LPA) Michael Bilger arrived unannounced at the facility to deliver findings for the allegations noted above. LPA met with Administrator Arlyn De La Cruz and explained the purpose of the visit. LPA displayed identification upon entry. During this investigation, LPA conducted interviews with two staff members and three residents in care. LPA also reviewed facility file documentation including appraisal and physician report for resident1 (R1). Additionally, LPA conducted a facility observation on 3-6-24.

Allegation: Staff did not ensure resident was provided comfortable accommodations for sleeping. This allegation stated facility staff made a resident sleep outside of facility. LPA conducted interviews, record reviews, and observation as noted above. Based on observation it was determined that the facility is providing regulatory required furniture and furnishing in all resident rooms including bed, night stand, storage space, and chair. Equipment was observed to be in adequate condition and suitable to accommodate comfort while sleeping and resting. Interviews conducted revealed that the facility {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20240228115950
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: J & M CARE HOME
FACILITY NUMBER: 397004273
VISIT DATE: 04/25/2024
NARRATIVE
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provides comfortable sleeping accommodations. Additionally, interviews revealed no corroborated statements of residents made to sleep outside of facility. As a result, there is not a preponderance of evidence to conclude staff are not ensuring comfortable accommodations for sleeping, therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff did not ensure resident had proper clothing violating resident rights. This allegation stated facility made a resident sleep outside and unclothed. LPA conducted interviews, record reviews, and observation as noted above. Based on observation it was determined that residents in care have appropriate amounts of clothing for various weather conditions and stored appropriately in rooms for use. LPA observed residents in care to be properly clothed during visit on 3-6-24. Interviews conducted did not reveal any corroborated statements of residents maintaining unsuitable amounts of clothing or being made by staff to sleep outside of the facility while unclothed. As a result, there is not a preponderance of evidence to conclude staff are not ensuring proper clothing for residents, therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Arlyn De La Cruz, and a copy of this report was provided to Arlyn. Appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20240228115950
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: J & M CARE HOME
FACILITY NUMBER: 397004273
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2024
Section Cited
CCR
87468.1(a)(3)
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Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature…This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on resident rights and submit proof of completed training to LPA by POC due date. Licensee to include training on staff disengagement from potential negative interactions with residents.
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 Based on interviews, S1 directed inappropriate language towards R1. This posed a potential health, safety, and resident rights risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4